and Lynaugh, 1992; Hanner et al., 1993), but do so with pride in the articulations across pathways that are already in place and that build on experience and demonstrated competence (Shalala, 1992). The need to address these issues is crucial, because too many ADN graduates and too few BSN and higher degree nurses are being produced relative to future needs (Aiken and Salmon, 1994). As health care delivery systems become increasingly primary care oriented and boundary spanning, the roles in which nurses will be needed will require more professional judgment and clinical autonomy (Clifford, 1990).

Expectations regarding educational level and competencies for advanced practice nursing roles are also in need of some clarification. The American Association of Colleges of Nursing (1994) has taken the position that all advanced practice nurses (APN) should hold a graduate degree in nursing and be certified, and that the American Board of Nursing Specialties should serve as the umbrella board to assist member-certifying bodies adopt professional and educational standards for the evaluation and certification of APNs. The effectiveness of this level of nurse has been documented (Office of Technology Assessment, 1986; Safriet, 1992); APNs provide needed services with consumer satisfaction, demonstrable effectiveness, and significant cost savings (Brooten et al., 1986; Pew Health Professions Commission, 1994a,b). The term APN is used, however, to refer to a number of roles—clinical nurse specialists, nurse practitioners, certified nurse midwives, and nurse anesthetists. Nurse practitioners have a history of providing primary health care services, while clinical nurse specialists have traditionally worked with less educated nurses to solve complex care problems, although psychiatric clinical nurse specialists and those majoring in community health or gerontology have also provided considerable first contact care. There is substantial debate as to whether the clinical nurse specialist role, with its systems orientation, should merge with the nurse practitioner role, with its emphasis on delivering primary care, so that the public will be less confused by different titles (Fenton and Brykczynski, 1993; Page and Arena, 1994).

At the doctoral level, the debate centers on whether the research focus of PhD programs should supplant the clinical focus of professional-degree programs (e.g., a doctorate of nursing science (DNS) program) (Flaherty, 1989; Martin, 1989). Most of the original DNS programs were as research minded as any PhD program; the decision to establish a DNS program rather than a PhD program was often a political decision rather than an academic decision (Downs, 1989). Professional-degree programs were more numerous when graduate schools were not very welcoming and took the attitude that a doctorally prepared nurse was an oxymoron. As the quality of nursing research became established, so, too, did PhD programs in nursing. There is, however, some renewed interest in professional-degree programs as a means of preparing clinical leaders capable of the evaluation research that is needed for a quickly changing health care delivery system (Starck et al., 1993).

All of the emphasis within nursing education on the spectrum of academic



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